Timothy C. Evans

A multifaceted intervention in support of diabetes treatment guidelines: a cont trial

OBJECTIVE in an academic family practice clinic, we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes. Providers received didactic training and computerized compliance feedback to support staged diabetes management, an evidenced-based approach to diabetes care. RESEARCH DESIGN AND METHODS one firm of the clinic practice received the intervention, the other served as the control group during a 14-month baseline period and a 14-month study period. HbA1(c) was the principal outcome measure. RESULTS there was a significant 0.71% difference in change in HbA1(c) values between the intervention and control firms (P=0.02). The subgroup with the greatest improvement in HbA1(c) was those subjects who started the intervention with a HbA1(c) above 8%. The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy. There were no changes in healthcare utilization or costs between the two firms. CONCLUSION in an academic family practice clinic, a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs. The improvement was mostly due to mitigation of the natural deterioration in control usually seen. Further efforts are required to involve all patients in co-managing their diabetes.

Effect of iron deficiency on energy conservation in rat liver and skeletal muscle submitochondrial particles

Submitochondrial particles prepared from liver and skeletal muscle of control and iron-deficient rats were examined for cytochrome content and for both energy-independent and energy-conserving functions. Liver submitochondrial particles appear quite resistant to iron deficiency with cytochrome content and electron-transferring or energy-conserving functions maintained at a level of 85% or better of normal. Iron-deficient skeletal muscle submitochondrial particles, in contrast, have decreased cytochrome content and only 15-20% of the normal capacity for oxidation through either complex I (NADH dehydrogenase) or complex II (succinate dehydrogenase). Energy-linked reactions which involve substrate oxidation/reduction (succinate----NAD+ reversed electron flow and succinate-driven energy-dependent transhydrogenation) are likewise markedly decreased, while ATP-driven energy-dependent transhydrogenation and mitochondrial ATPase are normal. Our data support the concept that iron deficiency leads to decreased electron-carrying capacity of iron-containing mitochondrial enzymes, with skeletal muscle being much more susceptible than liver, but that the mitochondria are otherwise normal with regard to energy conservation.

The military veteran to physician assistant pathway: building the primary care workforce.

The physician assistant (PA) profession emerged to utilize the skills of returning Vietnam-era military medics and corpsmen to fortify deficits in the health care workforce. Today, the nation again faces projected health care workforce shortages and a significant armed forces drawdown. The authors describe national efforts to address both issues by facilitating veterans’ entrance into civilian PA careers and leveraging their skills. More than 50,000 service personnel with military health care training were discharged between 2006 and 2010. These veterans’ health care experience and maturity make them ideal candidates for civilian training as primary care providers. They trained and practiced in teams and functioned under minimal supervision to care for a broad range of patients. Military health care personnel are experienced in emergency medicine, urgent care, primary care, public health, and disaster medicine. However, the PA profession scarcely taps this valuable resource. Fewer than 4% of veterans with health care experience may ever apply for civilian PA training. The Health Resources and Services Administration (HRSA) implements two strategies to help prepare and graduate veterans from PA education programs. First, Primary Care Training and Enhancement (PCTE) grants help develop the primary care workforce. In 2012, HRSA introduced reserved review points for PCTE: Physician Assistant Training in Primary Care applicants with veteran-targeted activities, increasing their likelihood of receiving funding. Second, HRSA leads civilian and military stakeholder workgroups that are identifying recruitment and retention activities and curricula adaptations that maximize veterans’ potential as PAs. Both strategies are described, and early outcomes are presented.

Pyridine nucleotide transhydrogenations in yeast

Though previously described as very low or absent in yeast, we find significant pyridine nucleotide transhydrogenation (NADPH + acetyl pyridine-NAD+----NADP+ + acetyl pyridine-NADH) activity in yeast extracts when assayed at pH 8-9, and describe here the subcellular distribution and separation of the various molecular forms contributing to the total activity in two yeast species. Gentle subcellular fractionation reveals transhydrogenase activity only in the cytosolic fraction of both Saccharomyces cerevisiae and Candida utilis while intact mitochondria and microsomes are without activity. On sucrose gradient centrifugation, this soluble cytosolic activity proves to be primarily in a high-molecular-weight (greater than 10(6)) band which has salmon-colored fluorescence on uv illumination. Sonication of the particulate subcellular fractions solubilizes substantial transhydrogenase activity from mitochondria of C. utilis (but not from S. cerevisiae) which on sucrose gradients consists of both high (greater than 10(6))- and low-molecular-weight active fractions, each with yellow-green fluorescence. Ammonium sulfate fractionation and sucrose gradient centrifugation of protein solubilized from whole yeast of both species by vigorous homogenization with glass beads confirms the presence and fluorescence of these various molecular weight forms. The relationship of these activities to other enzymatic activities (especially the mitochondrial external NADH dehydrogenase) is discussed.

Perioperative Management of Oral Antihyperglycemic Agents: Special Consideration for Metformin

Summary Diabetes mellitus is the most common endocrine metabolic abnormality, with eight million patients known to have the disease in the United States and an estimated equal number of people with diabetes who are as yet unidentified. Surgery is more common in patients with diabetes than in the general population. The metabolic consequences of surgery result not only from the underlying disease but also from the drugs used to treat diabetes. The available options for treatment of type 2 diabetes have increased significantly in recent years. In addition to the sulfonylureas, three other classes of antihyperglycemic agents (metformin, acarbose, and troglitazone) are available for use. The two most significant adverse effects of these drugs in the perioperative setting are hypoglycemia and lactic acidosis. Each of these serious side effects can be avoided or mitigated by proper attention to patient selection and careful patient monitoring during the perioperative period. Hypoglycemia occurs only with sulfonylurea, use, but hypoglycemia may be worsened by combined use of a sulfonylurea with a drug of another class. Lactic acidosis is associated with metformin use in the setting of renal failure or hypoperfusion (eg, congestive heart failure) and, although rare, has a high fatality rate. To decrease the risk of lactic acidosis, metformin must be discontinued before surgery and at the time of radiologic procedures in which intravenous contrast, which puts patients at risk for acute renal dysfunction, is used. Metformin may be reinstituted 48 hours after surgery or radiologic procedures if renal function is found to be normal and stable.

Veterans as physician assistants

ABSTRACTThe physician assistant (PA) profession emerged nearly 50 years ago to leverage the healthcare experience of Vietnam-era military trained medics and corpsmen to fill workforce shortages in medical care. In 2009, the American Recovery and Reinvestment Act Primary Care Training and Enhancement program was established to improve access to primary care. Training military veterans as PAs was again identified as a strategy to meet provider access shortages. However, fewer than 4% of veterans with military healthcare training are likely to apply to PA school and little is known regarding the factors that predict acceptance to training. In 2012, we surveyed all veteran applicants and a stratified random sample of nonveterans applying to PA training. We compare the similarities and differences between veteran and nonveteran applicants, application barriers, and the factors predicting acceptance. We conclude with a discussion of the link between modern veterans and the PA profession.